• A 58 year old presenting to us, stating
that she awoke that day feeling that the
room was spinning . She Had vomited
twice. She seemed anxious was unsteady
in her feet and was hyperventilating. She
didn’t have fever, but had a sore throat,
slight difficulty swallowing, slight
hoarseness and a red throat. Hallpikes test
induced vertigo and nystagmus.
• Vertigo is defined as the illusory sense of
movement or disorientation, indicates
disorder of the labyrinth or brainstem
• Presyncope is defined as a sense of near
faint typically due to transient hypotension
• Disequilibrium in the elderly is often
described as nonspecific slight
unsteadiness, particularly in turning and
indicates poor balance and strength
Is it common?
• Vertigo is a common condition in the community
• A fulltime GP can see 10-20 cases/year
• The diagnostic challenge is to differentiate peripheral from
very uncommon but very serious central causes such as
Main clinical features to be elicited in
the presence of acute vertigo are
• No history of hearing loss or tinnitus?
• No headache?
• Onset and duration of vertigo?
• Whether it is positional or sustained?
Nystagmus during Hallpike’s manoeuvre,
eye movement normal (except horizontal
No Horners, TMs normal, No new onset
deafness, No facial weakness , dysphagia,
dysphonia, must be able to walk even with
unsteadiness, no limb paresis, objective
ataxia or sensory loss
Red flags to look for on
• Any central neurological symptoms or
• Anew type headache
• Acute deafness
• Vertical nystagmus
• A 40 year old lady presenting with, sudden
onset of vertigo on turning the head, with
nausea. Halpikes shows rotatory
nystagmus. No headache, no vomiting, no
deafness, Rhombergs negative, gait
• A 45 year old lady presenting with
sustained vertigo, with unidirectional
horizontal nystagmus, no hearing loss or
tinnitus or neurological signs, has nausea
• What is the main differential diagnosis?
• Cerebellar stroke, of a case study of 240
patients with cerebellar stroke, 25 had
vertigo as sole feature. A simple test
called the ‘head thrust test’ tests the
vestibuloocular reflex and is always
abnormal in vestibular neuronitis. It was
normal in 24/25 of the cerebellar strokes.
• A 25 year old man presenting with vertigo,
hearing loss and tinnitus with symptoms
of urti, no neurological symptoms, head
thrust is positive, what is the likely
diagnosis, what will you do?
• A 80 year old man presenting with vertigo
unilateral hearing loss, tinnitus, headache,
facial pain and tingling, what needs to be
• A 50 year old presenting with vertigo,
tinnitus and fluctuating hearing loss with a
sensation of aural pressure